Provider Demographics
NPI:1508492448
Name:LEE, JIN SONG (DO)
Entity type:Individual
Prefix:
First Name:JIN
Middle Name:SONG
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 W CHARLESTON BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-0083
Mailing Address - Country:US
Mailing Address - Phone:702-671-5127
Mailing Address - Fax:702-671-6440
Practice Address - Street 1:86-260 FARRINGTON HWY
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-3128
Practice Address - Country:US
Practice Address - Phone:808-697-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-22
Last Update Date:2024-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
HI25502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program